library of congress 

MLCM 

2006/02417 

FT MEADE 
GenCol1 


PHYSICIAN 

PAYMENT 

REVIEW 

COMMISSION 

MONITORING 
ACCESS: 
REPORT TO 
CONGRESS 


No. 91-5 


May 1991 


2120 L Street, NW 
Suite 510 

Washington, DC 20037 
(202) 653-7220 
FAX (202) 653-7238 









LIBRARY OF CONGRESS 


MLCM 

2006/02417 



LC Control Number 



2002 435490 









PREFACE 


This report was submitted to Congress in accordance with the Commission’s responsibility 
under the Omnibus Reconciliation Act of 1989 to comment on the Department of Health 
and Human Services Secretary’s 1991 report to Congress on "Monitoring Changes in the 
Use of, Access to, and Appropriateness of Part B Medicare Services." 

Christopher Hogan, Ph.D. and Anne Lenhard Reisinger, Ph.D. were the Commission staff 
members principally responsible for developing this report. Michael Millman, Ph.D. 
provided much needed advice early in the development of this report. The Commission’s 
Advisory Panel on Access provided invaluable guidance throughout the preparation of this 
report. 


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CONTENTS 


Preface . i 

Executive Summary . iii 

Monitoring Access: The Commission’s Report to Congress. 1 

Background. 1 

The Secretary’s 1991 Report . 2 

Recommendations for HHS Action. 3 

Commission’s Monitoring Plans. 

Appendix A: Members of the Advisory Panel on Access. 10 

Appendix B: Draft Workplan on Access to Care . 11 

Background. 12 

Monitoring Access: The Conceptual Framework . 15 

Technical Notes on Measures of Access . 20 

Technical Notes on Sources and Uses 

of Data for Monitoring Access. 31 

Summary and Tentative Workplan. 38 

Table 1: Summary of Geographic Areas, Vulnerable Populations, 

and Measures of Access .. 30 













































































EXECUTIVE SUMMARY 


Maintaining acceptable levels of beneficiary access to care is crucial to the success of 
Medicare physician payment reform. The new payment system, however reasonable, will 
not be judged a success if despite gains in access for some beneficiaries, there are 
deteriorations for others. Thus, adequate monitoring of changes in beneficiary access to 
care is critical to the successful implementation of physician payment reform. 

The Omnibus Reconciliation Act of 1989 (OBRA89) directs the Department of Health and 
Human Services (HHS) to monitor changes in the utilization of, access to, and 
appropriateness of care. The HHS Secretary is directed to submit an annual report on the 
Department’s findings to Congress. OBRA89 also directs the Physician Payment Review 
Commission to review and comment on the Secretary’s report. 

Monitoring changes in beneficiary utilization of and access to care under payment reform 
will be an important part of the Commission’s work during the implementation phase of 
reform. Thus, in addition to reviewing the HHS plans, the Commission is developing its 
own plans for monitoring and analyzing changes in utilization and access. The 
Commission has convened an expert Advisory Panel on Access to assist it in both these 
tasks. 

On May 2nd, 1991 the HHS Secretary released his first report on beneficiary utilization 
and access. The report describes existing and planned data systems for monitoring changes 
in utilization and access. It devotes several chapters to describing the HHS plans for 
measuring and analyzing changes in the utilization of, access to, and appropriateness of 
care. It also discusses possible strategies for analyzing and monitoring outcomes of care. 

The Secretary’s report is a good first step in the development of the Department’s 
monitoring plans. HHS has undertaken major efforts to improve the timeliness and 
accuracy of Medicare claims data. The Department is also developing new data systems 
that will provide sorely needed information for tracking changes in beneficiary utilization 
and access. The Commission recommends that HHS: 

• develop a standardized system for the timely and routine release of public data 
on changes in the utilization of and access to care; 

• take steps to assure the availability of pre-reform baseline data for analysis; and 

• ensure that data system development and the dissemination of data proceed 
rapidly. 

Timely, routinely released data on the experience of beneficiaries during the 
implementation of payment reform will be needed to maintain beneficiary and provider 
confidence in the reform. In addition, data on the utilization of beneficiaries before the 



implementation of payment reform will be necessary to determine if the reform has caused 
any changes in utilization or access. 

The Commission further recommends that, in developing its plans to measure changes in 
utilization, access, and appropriateness, HHS: 

• include plans to measure utilization and access changes during the first year of 
payment reform implementation; and 

• more clearly specify its plans for long-run analyses of changes in utilization and 
access. 

The HHS plans currently concentrate on analyzing long-run changes over the course of 
reform implementation. The Commission believes that it is imperative that the 
Department track utilization and access changes during the first year of implementation. 
Further, the Commission suggests that the Department refine its long-run analytical plans, 
including a special focus on vulnerable beneficiary groups and measures of access 
appropriate to those groups. The Commission’s plans for monitoring changes in utilization 
and access to care, outlined in Appendix B of this report, could be used as a guide in 
developing the Department’s plans. 


IV 


MONITORING ACCESS: 

THE COMMISSION’S 
REPORT TO CONGRESS 


BACKGROUND 

The maintenance of acceptable levels of access to care is crucial to the success of Medicare 
physician payment reform. Payment reform is designed to replace Medicare’s method of 
payment based on customary, prevailing, and reasonable charges (CPR) with a more 
rational and equitable pattern of payment. Over the years, the CPR method resulted in 
inequitable payment differentials among services, localities, and physician specialties. The 
reform will replace CPR with a payment method that should ensure beneficiary access to 
care, maintain financial protection for beneficiaries, increase equity among physicians, and 
constrain the growth in Medicare spending. 

The payment reform is designed to achieve its goals through a resource-based fee 
schedule, limits on balance billing, and volume performance standards. The Medicare Fee 
Schedule will help to ensure beneficiary access to care and increase equity among 
physicians by rationalizing payments for physician services. Increases in payments for 
primary care services and decreases in payments for surgical and technical procedures will 
reduce payment disparities among specialties and services. By reducing geographic 
variations in physician payment, the fee schedule will reduce payment disparities among 
localities.' Reducing these payment differentials will not only result in more equitable 
treatment of physicians, but should also help to ensure that beneficiaries will have more 
uniform access to care. By limiting balance billing, the reform will provide financial 
protection for beneficiaries. Volume performance standards will constrain spending 
growth. 

The new payment system, however reasonable, will not be judged a success if despite gains 
in access by some, there are deteriorations for others. Thus, adequate monitoring of 
changes in beneficiary access to care is critical to the successful implementation of 
physician payment reform. 

The Omnibus Reconciliation Act of 1989 (OBRA89) directs the Secretary of the 
Department of Health and Human Services (HHS) to monitor changes in beneficiary 
utilization of and access to care and to report annually to Congress on its findings. The 
Secretary is to report on: 

• changes in the utilization of and access to services, by geographic area, population 
category, and type of service; and 



• possible sources of inappropriate utilization, and factors underlying changes in 
utilization and access, including factors relating to different services and to 
geographic and demographic variations in utilization. 

In addition, the Secretary may offer recommendations on: measures to address identified 
patterns of inappropriate utilization, improvements in utilization review, physician 
education or patient education, steps to address any problems of beneficiary access to care 
made evident by the monitoring process, and on any other matters that the Secretary 
deems appropriate. 

The Secretary issued his first report to Congress on May 2, 1991. OBRA89 directs the 
Commission to comment on the HHS report when it is issued each year. The 
Commission’s comments were developed in consultation with its Advisory Panel on Access. 

This report conveys the Commission’s concerns about the 1991 HHS plan for monitoring 
changes in the utilization of and access to care. The first section summarizes the 
discussion in the Secretary’s 1991 report. The next section discusses the Commission’s 
recommendations for action by HHS. Finally, the report discusses the Commission’s role 
in the process of monitoring changes in access to care. 


THE SECRETARY’S 1991 REPORT 

The HHS report emphasizes the importance of developing data systems that will supply 
the information needed to monitor changes in utilization and access. Over the last several 
years, HHS has been improving upon existing data systems and developing data systems. 
Recent improvements include: standardized definitions for Part B claims data, the addition 
of unique physician identifiers to claims data, improved timeliness and accuracy of claims 
data because of the OBRA89 requirement for direct submission of claims by physicians, 
and the development of the National Claims History System (NCH). Each of these 
developments should improve the accuracy and timeliness of Medicare claims data. 

Data systems under development by HHS include the Current Beneficiary Survey (CBS), 
the Uniform Clinical Data Set (UCDS), and the Medicare Beneficiary Health Status 
Registry (Registry). The CBS is a longitudinal survey of a large sample of Medicare 
beneficiaries. It will gather information on the beneficiaries’ utilization of and 
expenditures for medical services, health status and functioning, as well as the 
beneficiaries’ satisfaction with and perceptions of problems in gaining access to care. In 
addition, the CBS will be linked to Medicare claims files, making available detailed data 
on actual utilization. The Registry is a proposed longitudinal data base that would include 
a beneficiary survey and claims files which would allow tracking of the utilization and 
health status of a sample of beneficiaries for several years after the time of entrance into 
the Medicare program. 


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The HHS report first discusses the Department’s proposed efforts to track changes in 
beneficiary utilization. HHS plans to track changes in overall volume, changes in the 
volume and mix of services across areas, changes in the use of specific types of services, 
and changes for special population groups. The report also discusses the problems and 
issues with interpreting these volume changes. 

It goes on to outline the Department’s plans for analyzing changes in access to care. HHS 
plans to center its analyses around measures of barriers that beneficiaries encounter in 
attempting to use services and the extent to which beneficiaries receive medically necessary 
care. The CBS will be the major source of information on barriers to care. Claims data 
will be used to analyze patterns and changes in the receipt of medically necessary care. 

The HHS report discusses the Department’s approach to monitoring changes in the 
appropriateness of care. It notes that monitoring appropriateness will require the 
development of guidelines for appropriate care and measuring Medicare beneficiary use 
against those guidelines. HHS plans to rely on organizations such as the Agency for 
Health Care Policy and Research as a source of practice guidelines. The HHS Health 
Standards and Quality Bureau, through Peer Review Organizations (PRO), will do the 
monitoring of appropriateness of care. The Department will attempt analyze whether any 
trends in appropriateness are caused by payment reform. 

Finally, the report outlines the Department’s long-term approach to monitoring changes 
in the outcomes of medical care that beneficiaries receive. The Department’s analyses will 
center around three important outcomes of care: functional status, the need for follow-up 
care, and survival. Claims data, the CBS, PRO data and the Registry will supply the 
information for the Department’s analyses. 


RECOMMENDATIONS FOR HHS ACTION 

Monitoring of changes in beneficiary ut iliza tion of and access to care under physician 
payment reform will be a vital HHS function in coming years. While the Department’s 
is developing data systems that will collect timely and usable information, the Commission 
recommends that HHS: 

• develop a standardized system for the routine release of public data on changes 
in utilization of and access to care; 

• take steps to assure the availability of baseline data for analysis; and 

• ensure that data system development and the dissemination of data proceed 
rapidly. 

The Commission further recommends that, in developing its plans to measure changes in 
utilization, access, and appropriateness, HHS: 


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• develop plans to measure utilization and access changes during the first year of 
payment reform implementation; and 

• refine its plans for long-run analyses of changes in utilization and access, including 
a special focus on vulnerable beneficiary groups and measures of access 
appropriate to those groups. 

The following section discusses the Commission’s recommendations in more detail. 

Data Systems 

Timely and accurate data on the utilization experience of Medicare beneficiaries will be 
vital to the success of efforts to measure changes in access to care under physician 
payment reform. HHS has made large strides toward developing data systems that will 
produce detailed utilization data in a timely fashion. New data sources being developed 
by HHS such as the Current Beneficiary Survey, the National Claims History System, the 
Medicare Beneficiary Health Status Registry, and the Uniform Clinical Data Set will be 
important sources of information on the utilization patterns of Medicare beneficiaries. 

These new data sources will provide much more detailed utilization data than is currently 
available. The CBS will provide information on beneficiary perceptions of changes in 
access to care. Linked to both Part A and Part B claims files in the NCH through the 
Common Working File (CWF), the CBS will also allow tracking of the actual utilization 
experience of respondents. The UCDS will allow detailed clinical analyses of the medical 
treatment beneficiaries receive. The Registry should allow tracking of changes in health 
status and utilization for a cohort of beneficiaries from the time of entrance into the 
program. 

The new data systems will also make data available much more quickly than it is currently. 
The CBS data should become available for analysis 4-6 months after the completion of a 
round of data collection. The CWF claims authorization process will reduce the lag 
between the time a claim is paid and when the record of the claim becomes available for 
analysis from a year or more to close to half a year. The HHS efforts to develop more 
timely data systems are laudable. HHS should do all it can to keep up this momentum to 
get these data systems fully operational. 

There are, however, two major problems with the current data system plans. First, in 
order to assure the timely release of data to the public, HHS should develop a 
standardized data reporting system. Additionally, gauging the effects of payment reform 
on access will require the availability of data on the experience of beneficiaries in the 
period prior to the implementation of reform. 

Standardized Reporting System. The public release of data on changes in access is 
important to maintaining beneficiary and provider confidence in the payment reform. 


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Beneficiary groups, physician organizations and independent researchers concerned with 
changes in access should be able to obtain data with which to examine improvements or 
deteriorations in access under payment reform. The HHS plans do not include 
mechanisms for assuring that data is released routinely to the public. To facilitate the 
timely release of public data, HHS should develop a standardized series of regularly 
released reports on measures of beneficiary access to care. 1 This information should be 
released in forms that are relevant to the issues being analyzed. The reports should 
include changes in utilization and measures of access to care by geographic area and for 
potentially vulnerable segments of the beneficiary population. 

Public issuance of these data should be more frequent than the Secretary’s annual report 
to Congress. While the Secretary’s annual report should include the Department’s 
interpretation of these data, more frequent public release of this information will allow 
other interested parties to interpret these data as well. 

Baseline Data. The HHS discussion of data systems does not recognize the importance 
of developing good baseline data for the period prior to implementation of payment 
reform in January 1992. The Medicare Fee Schedule will be a significant change in 
Medicare payment policy, and about one-third of the total change payment levels will 
occur in the first year of implementation. Information on the period prior to the first 
implementation year will be necessary to measure changes in access to care due to 
payment reform. 

According to the HHS report, the first round of CBS data collection will not begin until 
1992, rather than in 1991 as originally planned. HHS staff have subsequently indicated, 
however, that the report was in error and that data collection will begin in the Fall of 1991. 
Because of the need for baseline data to evaluate the effects of payment reform, the 
Commission considers it imperative that the first round of data collection of the CBS begin 
on schedule in the fall of this year. 

Baseline claims data for the period before 1992 will also be needed to assess changes in 
access. To measure the effects of the changes, it will be important to compare utilization 
patterns from claims data for years prior to 1992 with the patterns in 1992 and beyond. 
To facilitate the development of information on the pre-1992 experience, HHS should 
release 1990 and 1991 claims data as soon as possible. 

Timeliness of Data. In addition to the data system problems identified above, the 
Commission wishes to emphasize the importance of timely release of data from Medicare 
claims files, the CBS, the Registry and the UCDS. The Department should make every 


1 The routine reporting of labor statistics from the Bureau of Labor Statistics is an analog for this type of data 
reporting. 


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effort to see that the time between data collection and the dissemination of data to the 
Commission and other researchers is minimal 

Measuring And Analyzing Changes In The Utilization Of And Access To Care 

The HHS report includes no plans for short-run (ie. during 1992) monitoring of changes 
in access and lacks detail on the Department’s analytical approach to long-run analyses of 
access to care. It is imperative that HHS attempt to monitor changes in beneficiary access 
during the first year of payment reform. Both short and long run analyses will require 
consideration of the beneficiary groups whose access to care may be affected by payment 
reform and appropriate measures of access to care. 

Short-run Analyses. Physician payment reform could cause significant changes in the 
levels of payment for various types of physician services. Under the Medicare Fee 
Schedule, payments for evaluation and management services, on average, will rise while 
payments for surgical and technical procedures will fall. Payments will typically increase 
in rural areas and fall in urban areas. Payment levels could change quite substantially. 
When the Medicare Fee Schedule is fully implemented, fees for many surgical and 
technical procedures will fall roughly 30 percent, while fees for primary care services will 
rise roughly 30 percent. At the same time, physicians’ ability to bill beneficiaries for the 
balance of their charge will be substantially limited. By 1993, balance billing for any 
service will be limited to just over 9 percent of the fee schedule amount for participating 
physicians. Despite the balance billing limit, beneficiary copayments could rise for services, 
like primary care, that will increase under the Medicare Fee Schedule. 

Since the Medicare Fee Schedule will be phased in over a number of years, only part of 
the payment shifts will occur in the first year of implementation. Approximately one-third 
of the total change in payment rates will occur in 1992, however, more than in any other 
single year. These first-year payment level changes are anticipated to be particularly large 
for some services. If these changes in physician payment or in beneficiary liability for the 
balance of the physician bill cause changes in access to care, these effects may well appear 
during the first year of implementation and could continue to develop over the full course 
of implementation. It will be important, therefore, to monitor any changes in beneficiary 
access to care during 1992 as well as changes that occur over the entire implementation 
period. 

The HHS monitoring plans concentrate primarily on the long-run analysis of access 
changes. HHS should be developing plans to measure any changes in access that occur 
during the initial phase of payment reform implementation. While it may be difficult in 
the first year to pinpoint with any surety access changes due to payment reform, HHS 
should attempt to track major changes or problem areas during the first year. Early 
identification of significant problems will allow for refinement of the policy before it is 
fully implemented. 


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The data required to monitor short-run changes in access to care should be readily 
available to HHS. Claims data through the CWF will be available routinely throughout 
1992. HHS could identify geographic areas or procedures with the largest payment 
changes and track utilization changes through the claims data. It could also identify 
potentially vulnerable beneficiary groups and track their utilization experience during 1992. 
Claims data from prior years would provide a baseline against which to gauge 
improvements or deteriorations in access to care. Information from the first round of the 
CBS could also point to potential problem areas or beneficiary groups. In addition to 
these large data sets, the Department could consider other sources of information on 
short-run changes in access. Beneficiary focus groups and surveys of carriers, for example, 
might help to identify short-run access problems. 

Long-run Analyses. HHS’s long run monitoring plans could be considerably improved with 
a more detailed consideration of measures of access to care and approaches to analyzing 
changes in access. The HHS report identifies three "definitions" of access: "measures of 
financial aspects surrounding access to care, ...the nature and prevalence of barriers to 
securing care,... [and] whether beneficiaries receive medically necessary services." The 
report briefly discusses several strategies for analyzing changes in these measures of access. 

As the HHS report recognizes, access is not easily definable and is thus not easily 
measurable. HHS’s three definitions of access to care could be operationalized in a 
number of different ways. The Commission, with the advice of its Advisory Panel on 
Access has developed a list of measures that HHS should consider using in its analyses 
(see Appendix B). 

HHS’s analytical strategies for monitoring changes in access to care also need more 
development. 2 As the Commission’s workplan described in the next section and in 
Appendix B illustrates, a number of approaches to measuring changes in beneficiary access 
to care could potentially yield valuable information on changes in access. In particular, the 
Commission recommends that HHS consider focusing analyses on potentially vulnerable 
groups of beneficiaries. 


COMMISSION’S MONITORING PLANS 

Monitoring changes in beneficiary utilization of and access to care under payment reform 
will be an important part of the Commission’s work during the implementation phase of 
reform. Thus, the Commission is developing its own plans for monitoring and analyzing 
changes in utilization and access. 


2 The report states that "part of HCFA’s research agenda in access to care is described in a forthcoming grant 
announcement." The grant announcement may contain more detail on the HHS plans. 


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The Commission’s initial monitoring and analysis activities will focus on changes in 
utilization and access rather than on appropriateness. The Commission has chosen this 
strategy in the belief that during the initial years of payment reform implementation, 
deteriorations and improvements in access to care are of principal concern and are more 
measurable than changes in outcomes or appropriateness of care. Analyses of changes in 
appropriateness and outcomes are important and may be included in later phases of the 
Commission’s workplan, but they require information on patterns of care across long time 
periods. 

OBRA89 required that the Commission consult with a panel of experts in commenting on 
the Secretary’s report. The Commission convened a panel of highly knowledgeable 
individuals including physicians, beneficiary representatives, and health services researchers 
(see list of members of the Advisory Panel on Access in Appendix 1). The Commission 
saw the value of making broader use of this group, not just to comment annually on the 
Secretary’s report, but to advise on the Commission’s workplan in this area. 

In February 1991, the Advisory Panel on Access began working with Commission staff to 
develop plans to monitor and analyze changes in access. The Commission’s workplan 
includes both short-run (during the first year of payment reform implementation) and 
longer-run analyses. The Panel helped to identify potentially useful measures of access to 
care and strategies for tracking changes in those measures. The Commission’s workplan, 
summarized briefly below, is discussed in more detail in Appendix B. 

The Commission analyses will employ a number of different measures of access. For 
example, access will be measured by the use of primary care and preventive services. 
Measures of primary care use include physician visit rates, the number of home visits, the 
ratio of outpatient visits to hospitalizations, and emergency room visits. The use of 
preventive services such as mammography and immunizations will also provide a measure 
of access to care. Another possible measure of access relies on sentinel events, health care 
incidents that either should not occur or should occur only rarely if beneficiaries have 

timely access to adequate primary care. 3 The stage of disease at first treatment and 

* 

mortality may also be indicators of access. 

Several areas of analysis will center around measures of provider activity or provider 
behavior, since beneficiary access may be affected by physician responses to changes in 
fees under the Medicare Fee Schedule. For example, changes in Medicare payment rates 
could cause physicians to limit the number of Medicare patients that they treat. 
Therefore, changes in the concentration of Medicare visits among physicians may be an 
indicator of changes in access. The number of beneficiaries changing physicians might be 
an additional indicator of physician willingness to serve Medicare beneficiaries. Also, 


3 Hospitalization with uncontrolled diabetes is an example. 


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increased use of public hospital facilities by Medicare beneficiaries may be an indicator 
of reduced access to private physicians. 

Some of the monitoring of changes in access will center on potentially vulnerable groups 
of beneficiaries. For example, analyses will track changes in access for beneficiaries with 
few financial resources. These beneficiaries include those without supplemental coverage 
(Medigap) and low-income beneficiaries. Approximately 20 percent of beneficiaries have 
neither Medicaid coverage nor Medigap insurance. Qualified Medicare Beneficiaries 
(QMBs), those beneficiaries whose cost sharing amounts are paid by Medicaid but who 
receive no other Medicaid services, could be adversely affected by changes in physician 
payment. Dual eligibles, beneficiaries receiving both Medicare and Medicaid, may also 
face new barriers to access. 

The Commission will also track those beneficiaries with special medical needs or that are 
difficult for physicians to care for. Special attention will be given to monitoring access for 
the institutionalized, the mentally and physically disabled, and the very elderly. 


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APPENDIX A 

MEMBERS OF THE ADVISORY PANEL ON ACCESS 


Perham Amsden 

American Association of Retired Persons 

Robert Blendon, Sc.D. 

Harvard School of Public Health 

Geraldine Dallek 
Medicare Advocacy Project 

Charles H. Epps, M.D. 

Howard University College of Medicine 

Lynn Etheredge 

Independent Consultant, Washington, D.C. 

Harold P. Freeman, M.D. 

Harlem Hospital Center 

Lucian Leape, M.D. 

Harvard School of Public Health 

Stephen H. Long, Ph.D. 

RAND Corporation 

Nicole Lurie, M.D. 

Department of Medicine 
Hennepin County Medical Center 

Ira Moscovice, Ph.D. 

School of Public Health 
University of Minnesota 

Martin F. Shapiro, M.D. 

UCLA School of Medicine 

Barbara Yawn, M.D. 

Private Practice of Medicine, Rochester, MN 


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APPENDIX B 

DRAFT WORKPLAN ON ACCESS TO CARE 





BACKGROUND 


The Physician Payment Review Commission’s Advisory Panel on Access was convened to 
help the Commission develop comments on the Secretary of Health and Human Services’ 
report on utilization, access, and quality. To achieve this end, the Commission asked its 
Panel on Access to outline a feasible system for monitoring changes in beneficiaries’ access 
to care. The Panel met on February 15, 1991 and suggested a number of approaches in 
this area. At a second meeting on April 22, 1991 the Panel refined a workplan for 
monitoring access to care. 

This appendix summarizes the Commission’s draft workplan for monitoring access to care. 
It brings together both a conceptual framework and detailed technical information on 
HCFA data processing systems and on the calculation of various indicators of access. In 
addition, it presents options for monitoring changes in Medicare beneficiaries’ access to 
care using data that are collected currently or will be routinely collected beginning in 1992. 


MONITORING ACCESS: THE CONCEPTUAL FRAMEWORK 

When considering how to measure access, the Panel favored an approach of monitoring 
trends in various access measures for very tightly defined populations. Broadly-based 
aggregate utilization statistics are insufficient for detecting changes in access to care. 
Monitoring must focus on the types of individuals and geographic areas that are most 
vulnerable to reductions in access or that are most in need of increased access to care. 
Measures of access to care must be as specific as possible. 

In considering when to monitor access, the Panel suggested a two-pronged strategy. First, 
some means to monitor access should be in place prior to January 1, 1992. This will 
assure timely response to any problems that may develop, and may provide much-needed 
objective data during the early implementation of Part B payment reform. However, more 
refined measures of access should be developed in later years as better and more 
comprehensive data become available. 

In considering who should monitor access, the Panel had fewer substantive 
recommendations. The Health Care Financing Administration (HCFA) has the most 
direct use of Medicare claims and other files. The Commission strongly endorses the 
timely public release of utilization and access statistics by HCFA. This will allow all 
interested parties to track developments in beneficiary access to care. Finally, the 
Commission will undertake its own research on beneficiary access to care based on HCFA 
administrative data and other data sources. 


TECHNICAL NOTES ON MEASURES OF ACCESS 

The Panel’s approach to monitoring access is based on comparing trends in utilization 
across various populations and geographic areas. The Panel identified the specific 


12 



geographic areas, vulnerable populations, and measures of utilization most relevant to 
monitoring access. Many of these access measures may feasibly be tracked using HCFA 
administrative data, but others may require special data collection efforts. 

The geographic areas of interest are of two types: areas in which fees are low or falling, 
and areas in which financial or health care resources are already stretched thin. 
Identification of the first type of area is fairly straightforward using Medicare and private- 
sector claims files. Identification of the second type of area may sometimes be more 
difficult. In particular, inner city areas and Health Professional Shortage Areas (HPSAs) 
are based on small and diverse geographic units and will require considerable effort to 
identify. 

Vulnerable populations are again of two distinct types: those with few financial resources, 
and those with special health care needs. It is possible to identify the elderly poor and 
near-poor beneficiaries when states purchase Part B coverage on their behalf, for 
example, dual eligible Medicare/Medicaid beneficiaries and Qualified Medicare 
Beneficiaries. However, HCFA administrative data may not allow other financially 
vulnerable populations, such as those without Medigap coverage, to be identified. 
Beneficiaries with special health care needs include the institutionalized, the mentally and 
physically disabled, persons with end stage renal disease (ESRD), and the very elderly. 
Most of these populations could be adequately tracked using administrative files and Social 
Security Administration data. 

Tightly-targeted measures of access can be constructed from several types of utilization 
data. First, clinically-based utilization measures may indicate the presence of access 
barriers. Hospitalization for certain "sentinel events", presence of advanced stages of a 
disease, and excess mortality may all indicate inadequate primary care. Other utilization 
measures indicate good access to care, including the use of primary care and preventive 
services. All of these measures are fairly easy to calculate from Medicare administrative 
data. 

Other measures center around providers rather than beneficiaries. Public urban hospitals 
and clinics are generally thought to be providers of last resort for many populations. 
Hence, a shift of beneficiary care to these settings could signal difficulty in receiving care 
in private physician offices. Similarly, an increased concentration of Medicare services 
among fewer physicians might indicate reduced access to mainstream health care. 
However, tracking the number of physicians serving Medicare beneficiaries appears 
difficult prior to 1992. 


TECHNICAL NOTES ON SOURCES AND USES OF DATA 

In the short run, the principal source of timely data is HCFA’s core claims file, the 
Common Working File (CWF). The CWF is a new claims processing system that captures 
all Part B physician services claims in a single centralized location. Extracts from this file 
could be used immediately to calculate access measures based on service utilization. 
Alternatively, special-purpose surveys of beneficiaries or physicians might be commissioned 
during the early stages of implementation of physician payment reform. 


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Over the longer term, many additional sources of data become available. Part B Medicare 
Annual Data (BMAD) files summarize a year’s worth of claims activity, and could be used 
in much the same way as the CWF. In addition, national surveys of beneficiaries and 
physicians may be used to look at access issues directly. Finally, several significant sources 
of non-Medicare data may be available for tracking utilization trends in the non-Medicare 
population. Divergences between Medicare and non-Medicare utilization could signal a 
loss of access by beneficiaries. 


SUMMARY AND TENTATIVE WORKPLAN 

The Commission’s first priority is to develop feasible access measures that may be 
implemented prior to 1992. Given the limited time frame, monitoring should probably 
focus on readily available HCFA claims data sets consisting of Part B claims for the 
standard 5 percent beneficiary sample, and Part A inpatient claims for all beneficiaries. 
Several years of these files are available, allowing the various measures of access to care 
to be tested on historical data. 

The Commission will also consider available survey information and will consider fielding 
its own survey of beneficiaries. While perhaps less precise than claims-based analysis, 
surveys could directly address questions of access to care in a timely fashion. 

Finally, the Commission reiterates its belief that HCFA should routinely report detailed 
Part A and Part B utilization statistics in a manner that will allow other interested parties 
to assess changes in beneficiaries’ access to care. A common set of data available to all 
would enhance dialogue on beneficiaries’ access to care and preserve confidence in the 
Medicare program. 


14 


















































































































































MONITORING ACCESS: 
THE CONCEPTUAL FRAMEWORK 


Three broad strategic areas need to be addressed in monitoring the access impacts of 
physician payment reform. First, how should access to care be measured? Second, when 
should it be measured, in the short run or in the long run? Finally, who should be 
responsible for monitoring changes in access? 


HOW TO MEASURE ACCESS TO CARE: AREAS, POPULATIONS, AND MEASURES 

The Panel suggested monitoring access by tracking trends in utilization across populations 
and geographic areas. Populations or areas most vulnerable to reductions in access will 
be contrasted to populations and areas in which access problems are unlikely to develop. 
Declines in access measures for those most at risk relative to those least at risk would be 
a warning that beneficiaries may be having a greater difficulty obtaining adequate care. 

This approach requires that the areas, populations, and measures be as tightly defined as 
possible. Access is likely to deteriorate first for small subsets of the population or for 
specific types of medical care. For example, problems may be more likely to arise in those 
geographic areas having the steepest fee reductions. Within those areas, the impact might 
be most strongly felt by beneficiaries with exceptional needs, such as the home-bound, 
institutionalized, or mentally disabled. For these beneficiiaries, reductions might first 
appear in specialty services. A broad-based, untargeted approach to monitoring access 
might never detect these deteriorations in access or might detect changes only after 
substantial problems had already developed. 

Because such a narrowly targeted approach is called for, the Panel identified specific 
geographic areas, vulnerable populations, and measures of access. These are outlined 
briefly here, and in more detail in a later section of this appendix. 

Geographic Areas 

The panel identified a number of geographic areas that should be studied separately. First 
and most obviously, areas where Medicare rates will be substantially below private sector 
rates, and areas where Medicare rates will fall most substantially should be analyzed 
separately. Physicians in these areas will have the lowest financial incentives to serve 
Medicare beneficiaries. Second, areas with physician shortages, such as Health 
Professional Shortage Areas (HPSAs) should be given particular attention. Finally, inner 
city areas and frontier rural areas generally suffer both from poverty and from a lack of 
providers, and so would be most vulnerable to reductions in access if even a few physicians 
became reluctant to treat Medicare beneficiaries. 


15 



Vulnerable Populations 


The Panel identified several vulnerable populations that should be the focus of monitoring 
efforts. One such population consists of beneficiaries who have limited ability to pay for 
services. This includes beneficiaries without supplemental coverage (often referred to as 
Medigap), and low-income beneficiaries, including Qualified Medicare Beneficiaries 
(QMBs) and beneficiaries receiving both Medicare and Medicaid. A second vulnerable 
population consists of beneficiaries with complex or ongoing medical needs, individuals 
who may be more difficult or less remunerative for physicians to treat. This population 
includes the institutionalized, the mentally and physically disabled, persons with end stage 
renal disease (ESRD), and the very elderly. 

Measures Of Access 

The panel suggested several approaches to measuring changes in access to care for these 
target populations. One such approach was the incidence of sentinel events, which are 
medical events which should happen only rarely if beneficiaries are receiving adequate 
care. For example, hospitalizations for diabetes and hypertension might indicate 
insufficient primary care and outpatient management. A second measure was the stage 
of disease at presentation. Persons with poor access typically present at an advanced stage 
of disease. Similarly, excess mortality may be an indicator that proper care is not being 
received. Other measures are more directly linked to good access to care. These include 
the use of preventive services, and the use of primary care services. In both cases, higher 
use rates indicate a lower likelihood of poor access to care. 

Other measures of access were based on providers of care. First, the Panel suggests that 
utilization in public urban hospitals and clinics may be an indicator of poor access. These 
institutions are generally thought to be providers of last resort for many populations. 
Hence, a shift of beneficiary care to these settings could signal difficult in receiving care 
in private physician offices. Second, the Panel suggested that an increasing concentration 
of care among fewer physicians might indicate a loss of access to mainstream medical care. 
The Panel suggested tracking the fraction of physicians serving Medicare patients, the 
concentration of Medicare services across physicians, the number of beneficiaries changing 
physicians, and reasons for loss of usual source of care. 


WHEN TO MEASURE ACCESS TO CARE: IMMEDIATELY AND IN THE LONGER 
TERM 

In considering when to measure access, the Panel suggested that some system for 
monitoring access should be in place by 1992, and that more detailed analysis should be 
performed in later years as more complete and detailed data became available. The large 
payment changes that will occur in 1992 suggest that access problems, or at least the 
perception of access problems, may begin to develop immediately after implementation of 
payment changes. Thus, a system for monitoring changes in access should be in place 
prior to the implementation of payment reform in 1992. However, monitoring is also 
needed in the longer run. Many of the effects of the payment changes, and many of the 


16 



more detailed datasets will not be available until several years into the transition to the 
new physician payment rates. 

The Immediate Need For Measures Of Access To Care 

There are three rationales for putting some access monitoring process into place in time 
for the 1992 implementation of physician payment reform. First, there may be immediate 
and real reductions in access due to the payment changes. Second, it may require several 
years to identify and address problems in access if we rely solely on detailed annual 
datasets such as the Current Beneficiary Survey. Finally, hard evidence on changes in 
access to care may be particularly useful during the initial phases of payment reform. 

The first factor to consider is the probability that problems in access will develop soon 
after January 1, 1992. This is of course difficult to assess. Part B payment restraints 
through 1989 do not seem to have caused reductions in access for the typical beneficiary. 
However, this may not extrapolate to the large payment changes that will take place in 
1992 and later years. 

Perhaps the most positive statement that can be made is that problems are more Likely to 
occur with physician payment reform than they were with Medicare hospital payment 
reform. A comparison of physician payment reform and the Medicare Prospective 
Payment System (PPS) shows why that may be true. 

First, payments during the initial years of PPS were quite generous, with hospital operating 
profit margins exceeding 14 percent on average. In contrast, real Part B fees have fallen 
15 percent since 1988, and may continue to fall after 1992 due to certain technical aspects 
of the transition to the new fee schedule. Second, PPS generated smaller initial changes 
in payment rates, with 75 percent of inpatient operating payments and 100 percent of 
other payments (capital, outpatient services) based on the hospital’s own cost experience. 
In contrast, all provider-specific rates disappear during the first year of physician payment 
reform, and locality-wide average payments are the only vestige of the current system that 
will remain after 1991. Finally, the typical hospital may have been unable to reduce its 
Medicare patient load. Medicare accounts for about 40 percent of hospital inpatient 
revenue, and the decision to admit patients is made by the physician, not the hospital. In 
contrast, Medicare constitutes a smaller proportion of revenues for many specialties, and 
physicians have a direct financial interest in the level of Part B fees. 

The second factor arguing for immediate monitoring of access is the length of time 
necessary to obtain, analyze, and act upon the detailed annual datasets to be produced by 
HCFA. The first of these datasets will appear only in late 1993 or early 1994. The cycle 
of analysis, recommendation, and legislation could take another year, meaning that 
problems occurring in 1992 might not be corrected until 1995. Given this lag, it may not 
be advisable to wait for complete annual data sets before judging increases or decreases 
in access to care. 

A final factor to consider is the need for solid objective data during the initial transition 
to the fee schedule. Any program change of this magnitude is likely to generate 
considerable criticism and negative anecdotal evidence. This could create a perception of 


17 


reduced access even if access is not in fact reduced. Clear and unambiguous information 
during this period may help maintain the integrity of the reforms during their initial 
implementation. 

The Need For Long-Run Monitoring Of Access 

There are several reasons to develop measures of access that cannot be implemented until 
several years after 1992. First, many of the potential impacts of payment changes may 
take some time to appear. Second, better data become available as time passes. Third, 
a longer time frame allows more fine tuning and testing of access measures. 

One reason to pursue access monitoring over the longer term is that the impacts of 
payment reform may not be fully felt until years later. First, while payment rates will 
change most dramatically in 1992, rates will continue to change through 1996. Many 
physician practices seeing a decline in fees in 1992 will probably see further declines in 
later years. Second, physicians and beneficiaries may take several years to react to the 
new rates, modifying practice patterns and payer mix over the course of the transition. 
Finally, the health effects of some types of reduced access to care may take years to 
develop. In particular, measures based on death rates and on hospitalization for sentinel 
events may not change until well after access to primary care has declined. 

A second reason for planning a long-term access strategy is that more complete and 
detailed data become available. Immediately available data may be limited to simple 
claims writeoffs. These files are always subject to uncertainty due to fluctuations in the 
number of outstanding unprocessed claims (claims runout), and they will not include 
information on such items as health status. Annually produced datasets would include the 
Current Beneficiary Survey (CBS) and the Part B Medicare Annual Data (BMAD) files 
from HCFA, and the Health Interview Survey from the National Center for Health 
Statistics. These files are not subject to the uncertainties caused by claims runout and they 
contain more complete information on the beneficiaries. However, complete annual data 
are typically not available until one to two years after data collection ends, meaning that 
the first detailed analysis of the access impacts of the 1992 changes cannot be made until 
late 1993 or early 1994. 1 

Finally, much of the developmental work for the proposed measures of access still needs 
to be done. Reliable measures of access may not be available in time for the initial 
implementation of payment reform. In the interim, research may be directed toward 
developing and testing new measures of access to care for implementation on the more 
complete datasets. 


1 For example, data from the first set of post-1991 CBS access questions will be available in June 1993 at the 
earliest, but final tabulations will not be available until December 1993. Similarly, the 1992 BMAD files will 
probably be released around the end of 1993. 


18 







WHO SHOULD DO THE ANALYSIS? 


Perhaps the most difficult question to answer at this time is who should monitor access. 
Clearly the burden of work must rest primarily with HCFA, since HCFA will have the use 
of all Part B claims data. In addition, the Commission may wish to establish greater access 
to Medicare claims files for the purpose of monitoring changes in beneficiaries’ access to 
care. Finally, the Panel urges that the Secretary routinely release utilization data that 
would allow any interested parties to track measures of access. 

Practical considerations alone suggest that HCFA must play the major role in monitoring 
access to care. First, the principal source of Medicare claims data is huge. Estimates of 
the size of one year of Common Working File Part B records range from 1500 to 7000 
standard reels of computer tape, depending upon what data items are included. Because 
HCFA staff will necessarily have more direct access to this data, they will be better able 
to calculate some of the measures of access. Second, some elements of the data set cannot 
be released to individuals outside Health and Human Services. In particular, the Unique 
Physician Identification Numbers (UPINs) probably will not be available to researchers, 
although some scrambled form of the UPINs may be made available. Thus, detailed 
analysis of certain aspects of the data such as characteristics of physicians may best be 
done by HCFA personnel. 

However, other parties may also play a part in monitoring access to care. The 
Commission may wish to perform its own analyses of HCFA claims files to assure that 
certain measures of access are calculated. However, given the lack of specific detail in the 
Secretary’s report on utilization, access, and quality (DHHS 1991), it is difficult at this 
point to say what measures the Secretary actually plans to calculate and publish. Thus, it 
is unclear to what extent the Commission will engage in actually analyzing claims files in 
its efforts to monitor access. 

Some analyses of data other than HCFA claims files may more appropriately be done 
under the auspices of the Commission rather than by HCFA. For example, physicians or 
beneficiaries might respond to surveys differently depending upon the sponsor. Thus, the 
Commission could play a valuable role in supplementing the HCFA research agenda in 
these areas. 

Finally, the Commission recognizes that the timely release of data by HCFA as a crucial 
element in this plan. Many of the data sources are too large to be released in their 
entirety by HCFA. However, useful summary statistics could be produced and made 
available to interested parties. Routine release of such summary data, with or without 
further analysis by HCFA, would allow interested parties such as beneficiary organizations 
to track changes in access to care. 


19 











'»*• • 
























• 










































. 
































































TECHNICAL NOTES ON 
MEASURES OF ACCESS 


This section of the workplan collects background information on the geographic areas, 
vulnerable populations, and measures of access identified by the Panel. The underlying 
question is whether these areas, populations and measures can be identified using HCFA 
claims files. Table 1 at the end of this section provides a summary of the areas, 
populations, and measures discussed here. 


GEOGRAPHIC AREAS 

The Panel identified several geographic areas of interest. This section reviews some 
evidence on the ability to identify these areas and track beneficiaries within these areas 
using Medicare administrative data. 

Frontier Rural Areas 

Frontier rural counties are counties with fewer than six inhabitants per square mile. With 
only a handful of exceptions, these counties all are west of the Mississippi river. These 
areas are marked by relatively thinly-spread health care resources, and inhabitants are 
generally thought to have to travel further to obtain medical care. In these areas, access 
could be jeopardized if only a few providers decided not to see Medicare beneficiaries. 
In 1988, 1.2 percent of Medicare beneficiaries lived in frontier rural counties. 

It is a relatively straightforward task to identify frontier rural counties using the .Area 
Resource File (ARF). Once those counties are identified there are two ways in which 
claims information may be obtained. First, HCFA already processes many claims into 
county aggregates. Thus, county of residence aggregate files could readily be made 
available. However, these files are processed only with a considerable lag, usually contain 
only summary information, and would not serve for a rapid analysis of changes in 
utilization just pre and post the introduction of payment reform. Alternatively, HCFA 
staff may draw samples of records from the CWF based on county of residence. 

Inner City .Areas 

Identifying beneficiaries in inner city areas is a much more difficult task than identifying 
those in frontier rural areas. For the purpose of tracking health care use, inner city areas 
are generally defined as areas with low average incomes, high poverty rates, and few health 
care providers. Because these areas must be defined at the sub-county level, readily- 
available county-level files such as the ARF are not useful in identifying them. 

One approach to identifying such areas would rely on commercially available files 
tabulating information for individual Census tracts or ZIP codes. These files typically 
record information on average income. These files might be supplemented with counts of 
patient care physicians to generate a list of ZIP codes for a specific definition of inner-city 


20 



areas. Once ZIP codes were identified, records could be drawn from the CWF based 
either on the ZIP code, or more easily, based on the HICs of individuals living in those 
ZIP codes. 

An alternative approach could be undertaken from HCFA claims files. Beneficiary ZIP 
code and buy-in status could be used to identify ZIP codes with a high proportion of poor 
and near poor beneficiaries, those who are Medicaid-eligible or who are Qualified 
Medicare Beneficiaries. As with the first approach, counts of physicians could then be 
used to identify underserved pockets of poverty within cities. 

There is a potentially important complication to either of these methods. Because the ZIP 
code is based on the mailing address of the Social Security check, there may be leakage 
across the borders of inner-city regions. ZIP code zones tend to be geographically small 
in cities, making this a more significant problem than the similar problem faced in placing 
beneficiaries into frontier rural counties. 

Health Professional Shortage Areas 

Health Professional Shortage Areas (HPSAs) are designated by the Health Resources and 
Services Administration (HRSA) in the Public Health Service. HRSA has used the 
HPSAs to help determine the allocation of Public Health Services Corps physicians. A low 
physician-to-population ratio is the prime determinant of HPSA status. 

Medicare currently pays a bonus payment for services provided in HPSAs. Prior to 1991, 
a five percent bonus was added to physicians providing services in some categories of rural 
HPSAs. As of January, 1991, a 10 percent bonus is paid for services provided in all rural 
and urban HPSAs. 1 HCFA staff provided the Commission with the following outline of 
claims processing for HPSAs: 

Medicare Part B carriers must know which bills are paid in HPSAs because payment rates 
differ between HPSA and non-HPSA areas. Identification of those bills is, however, a 
lengthy process. It begins in the Public Health Service, which provides a "narrative list" 
of HPSAs to HCFA, literally a written description of each HPSA. HPSAs may be 
counties, Census tracts, or other geographic areas, or may be specific to particular 
populations within geographic areas, for example, individuals below the poverty line. 
HCFA passes this narrative list on to the carriers with instructions to draw maps or 
otherwise make information about the locations of HPSAs available to physicians. 

Physicians must identify services provided in HPSAs on the claim form in order to receive 
the bonus payment. Prior to January 1, 1991, this was done by adding "rural" to the 
narrative place-of-service description. 2 Carriers, however, translated these expanded 
place-of-service narratives into the standard place of service codes when submitting the 


1 Actually, the additional payment is 10 percent of the 80 percent of the bill paid directly by Medicare, or 8 
percent of the allowed charge. 

2 For example, hospital inpatient - rural. 


21 



data to HCFA. Thus, prior to January 1, 1991, information on individual services provided 
in HPSAs was not available on HCFA claims files. 3 After January 1, 1991, however, the 
system for reporting HPSA services changed. Rather than using a place-of-service code, 
physicians were instructed to use a new HCPCS code modifier to show that the services 
was provided in a HPSA. 4 This modifier would be retained during claims processing, and 
so should be available on HCFA claims datasets. However, the extent of compliance with 
this new regulation is not yet known. Currently, HCFA tracks centrally only the quarterly 
aggregate number of checks and total bonus payments for services delivered in HPSAs. 

If shortage designation is not accurately recorded, obtaining information on beneficiaries 
in those areas would require a considerable amount of work. HPSAs are quite complex. 
Even those that are strictly geographically defined can be areas from whole counties down 
to individual census tracts or magisterial districts. These areas will not cross-walk exactly 
to ZIP codes, and to date Commission staff have not found an approximate ZIP code 
mapping for all U.S. HPSAs. 5 Thus, such a cross-walk might have to be generated by 
overlaying physical maps of HPSAs with ZIP code maps. 

Medically Underserved Areas 

Medically Underserved Areas (MUAs) are an alternative to HPSAs for identifying areas 
with potentially poor access to care. The MUAs share many of the technical problems of 
the HPSAs. They are not defined in units that are easily traceable through the machine 
readable files. In addition, they are not the basis for the Medicare 10 percent bonus 
payment, and so are not recorded on HCFA claims files. 

Areas/Specialties With Large Price Declines 

The Commission’s simulations will be used to identify areas and specialties within areas 
that will experience large fee declines during the transition to the Medicare Fee Schedule. 
Currently, those simulations are being fine-tuned to represent the best available data on 
post-1992 payment rates. Later this year, Commission staff will estimate gains and losses 
by specialty and payment area. Because fees are set using these payment area definitions, 
it will be quite easy to identify all services paid for in the various areas. 


3 On the 1989 BMAD file, three carriers (Virginia, Louisiana, and the Railroad Retirement carrier) used a 
unique set of place of service codes to report services delivered in shortage areas. 

4 The HCFA Common Procedure Coding System (HCPCS) code is a five-digit code identifying the service 
performed by the physician. A two-digit modifier is sometimes appended to the HCPCS code to further define 
the service. The modifiers QB and QU are now used to indicate that a service was provided in a HPSA. 

5 One study using National Medical Expenditures Survey data cross-walked late-1970s HPSAs to ZIP codes. 
This took approximately two person-weeks of effort (Personal communication with Amy Bernstein, Prospective 
Payment Assessment Commission). 


22 



NVV 




Areas With Large Medicare/Private Fee Differentials 

While Medicare fee data are publicly available, there is little reliable private-sector fee 
information. Previous staff work with the Blue Cross and Blue Shield Association verified 
that there is considerable geographic variation in the gap between BC/BS and Medicare 
payment rates (PPRC 1990), but the BCBSA cannot identify individual areas in its 
analyses. 

Of the potential data sources in this area pursued by the staff, the MEDSTAT data appear 
most promising. The MEDSTAT database is a collection of claims for approximately 100 
very large employers. This data set is rather expensive, but it has a number of advantages. 
First, it has a fairly representative sample of private sector payer mix, including both 
BC/BS and commercial payers. It also has a reasonably uniform geographic distribution 
across urban areas, though relatively few claims are filed from rural areas. 

Commission staff have contracted with MEDSTAT for the purchase of data which may 
allow comparisons between 1989 Medicare rates and 1989 private sector rates. From this, 
staff can use the Commission’s simulations to project the approximate differentials that 
will occur in 1992 and later years. If the MEDSTAT data prove usable and reliable this 
analyis may be repeated in later years. 


VULNERABLE POPULATIONS 

The Advisory Panel on Access identified a number of populations most vulnerable to 
reductions in access to care. This section collects some background information on 
identifying those populations using the Medicare administrative files. 

Old Old 

This population can be easily identified from HCFA administrative data. Various HCFA 
eligibility files contain date of birth information, which can then be linked to the Health 
Insurance Claim (HIC) number (Social Security or Railroad Retirement Number plus 
Beneficiary Identification Code). HCFA uses the HIC on all claims processed, so service 
utilization by this population should be easy to track. It may be necessary for HCFA to 
encrypt the HICs to maintain the confidentiality of the records. However, because 
HCFA’s encryption algorithm is unique, the Commission may also request the beneficiary 
information with encrypted HIC and merge the beneficiary information onto the claims. 

A typical line for distinguishing the "old old" beneficiary is age 85. This would capture 10 
percent of the aged beneficiary population and 12 percent of Part B outlays. 

Disabled 

As with the old old, HCFA administrative records allow the disabled to be identified 
directly. In this case, the "current reason for entitlement" field identifies all disabled 
beneficiaries. Disabled beneficiaries constitute about 10 percent of the beneficiary 
population (2.7 million disabled versus 28.5 million aged beneficiaries in 1988). 


23 



Identifying the mentally and physically disabled within this category of beneficiaries may 
be quite difficult. Routinely available produced Medicare statistical files do not maintain 
a finer breakout of the "reason for entitlement" field. However, Social Security 
Administration files probably do record a detailed "reason for entitlement" for the 
disabled. Commission staff will check with HCFA personnel to see whether type of 
disability recorded on the SSA files may be written onto HCFA claims records. If not, 
staff could try to identify the mentally disabled through patterns of service use (eg., 
psychiatric services). This may require a special request for data from HCFA in order to 
be able to attach beneficiary reason for entitlement onto the Commission’s existing sample 
of Part B beneficiary claims. 

ESRD Beneficiaries 

ESRD beneficiaries are identified in the "reason for entitlement" field. In addition, the 
standard HCFA beneficiary sample contains records for five percent of non-ESRD 
beneficiaries and 100 percent of all ESRD beneficiaries. Thus, it would be particularly 
convenient to track utilization by this beneficiary population. 

Institutionalized 

Commission staff have been discussing the problem of identifying the institutionalized with 
HCFA personnel working on the Current Beneficiary Survey. They suggest that it may be 
difficult to characterize accurately the institutionalized beneficiary population. 

Staff can identify beneficiaries with Part B charges in nursing home settings. In addition, 
some Part A payments may be identifiable for nursing home care following acute inpatient 
stays. However, these markers would ignore beneficiaries with no claims, and may 
imperfectly identify beneficiaries who are well enough to travel to physician offices or 
other settings for their Part B care. At the very least, Commission staff will try to 
benchmark counts of institutionalized individuals derived from claims analysis against 
counts from national surveys. In addition, this would not accurately track beneficiaries as 
they move into and out of institutional settings. That is, a listing of institutionalized 
individuals derived from 1990 data may be a poor proxy for the institutionalized 
population in 1992. 

Buy-In Status (Medicaid, QMBs) 

States may purchase Part B coverage for their Medicaid beneficiaries (dual eligibles) and 
for individuals near the poverty line but not Medicaid eligible (Qualified Medicare 
Beneficiaries or QMBs). HCFA administrative files note the buy-in status of Medicare 
beneficiaries, so this population could be easily identified. However, because buy-in status 
may change over time, there may be some discrepancies between beneficiaries identified 
by this method in one year and the population of beneficiaries with state buy-in in the next 
year. 

Approximately 9 percent of beneficiaries were enrolled in Part B under state buy-in 
agreements in 1989. This varies considerably across states, however. For example, nearly 


24 


25 percent of Mississippi beneficiaries were enrolled under this program, while for several 
states approximately 3 percent of beneficiaries were so enrolled. 

Payment policies regarding these beneficiaries vary considerably across states. States pay 
the copayments for these beneficiaries, but typically will pay these copayments only in 
reference to their local Medicaid fee schedules. Thus, in many states, if the Medicaid fee 
is less than 80 percent of the Medicare allowed charge, the physician collects no 
copayment. Commission staff have so far been unable to locate a listing of state policies 
in this area. A survey of state Medicaid programs may have to be conducted to determine 
which states pay at their Medicaid fee schedules and which states pay the full Medicare 
rate. 

Ethnicity 

Ethnicity is identified on several of the Medicare statistical files. The categories are black, 
white, other, and unknown. 

The Poor 

It is probably not possible to identify the non-Medicaid/non QMB poor. While it is 
possible, on a special request basis, to obtain files with social security income, that variable 
has not proven very useful in identify poor individuals in previous Commission staff work. 
However, some survey data may provide information on income. 


MEASURES OF ACCESS 

Finally, the Panel suggested several types of measures of access to care. This section 
provides some small amount of background detail on calculating those measures from 
HCFA administrative data. 

Sentinel Events 

The notion of avoidable illness and avoidable death underlies the sentinel event approach 
to monitoring access. Sentinel events are serious medical conditions which could have 
been avoided or from which death could have been avoided (United Hospital Fund 1988). 
They have been classified into events for which any incidence indicates poor care (ie., 
events which should never happen) and events for which a high incidence indicates poor 
care. Little of the existing analyses of sentinel events has focussed on the Medicare 
population, although under one definition 60 percent of sentinel events occur in the over- 
65 population (United Hospital Fund 1988). 

At least two questions need to be addressed before beginning to apply the sentinel event 
approach to the Medicare population. First, of the sentinel events identified elsewhere, 
which ones are most applicable to the Medicare population? Second, how large a 
population is needed to guarantee a reasonably stable estimates of the incidence of 
sentinel events over time? 


25 


Commission staff began to examine the questions of incidence and stability for a small 
number of sentinel events. Criteria for identifying four sentinel events using ICD-9-CM 
codes on hospital discharge abstracts were taken from a recent Health Resources and 
Services Administration report (HRSA 1987). Part A records from the Medicare 
Automated Data Retrieval System (MADRS) were analyzed for a sample of about 100,000 
beneficiaries residing primarily in the Los Angeles area. The annual incidence of these 
four sentinel events per 1000 beneficiaries varied considerably, from 0.2 events per 1000 
beneficiaries for invasive cervical cancer to 19 events per 1000 beneficiaries for 
uncontrolled hypertension. 

The relatively low incidence of these conditions means that fairly large populations are 
needed to obtain stable use rates. Thus, this technique probably cannot be applied to 
populations of fewer than 50,000 beneficiaries. In smaller populations, even very large 
year-to-year fluctuations could be the result of natural random variation in incidence. 

Stage Of Disease 

The concept of disease stage originated in oncology, where the progress of a cancer was 
tracked from localized involvement through systemic involvement, organ failure, and death. 
Individuals with poor access to primary care might first present to a physician with their 
disease at a more advanced stage. Thus, stage of disease at first treatment may be a good 
clinical indicator of access to care. 

In some instances, the stage of a cancer might be subsumed into the sentinel events 
approach if certain subsets of ICD-9-CM codes would allow invasive and metastasized 
cancers to be identified. More formal approaches are available based on the diagnoses 
and procedures recorded in Part A hospital data. If these approaches to identifying stage 
of disease are not satisfactory, the success of such a project might depend on crosswalking 
information from cancer registry data onto the Medicare claims files. Large-scale mapping 
of machine-readable cancer registry data has been attempted before, 6 and there are fairly 
standard procedures for matching discharge abstracts to other data files. 

Because the best indicator would be stage of disease at presentation, this approach would 
ideally require a fairly substantial time series. Such a time series might be feasible if the 
indicator is limited to stage at first hospitalization. Because the Medicare hospital 
discharge abstract files are fairly small (10 million records annually) and complete, it would 
be feasible to perform a retrospective search within a multiple-year window to identify a 
patient’s first hospitalization for a given condition. 


6 For example, the Hospital Cancer Clinical Research Project (HCCRP), a joint undertaking of the National 
Cancer Institute and the Agency for Health Care Policy and Research, linked data from 10 regional cancer 
protocol registries to a discharge abstracts provided by a few hospitals. However, the project, begun in 1984, is 
not yet finished, so it is difficult to tell how accurately such data may be matched. 


26 



Primary Care Utilization 

The Panel suggested a number of access measures based on utilization of primary care 
services. These included the gross visit rate, annual probability of an office visit, number 
of home visits, ratio of outpatient visits to hospitalizations, emergency room (ER) visits, 
or ER visits as a percentage of all visits, and the distribution of office visits across 
beneficiaries. 

With the exception of home visits, calculation of all these measures should be fairly 
straightforward. For home visits, there is a complication in that visits by home health 
agency employees might substitute for visits by physicians. Thus, counts of physician home 
visits might misstate the degree of home-based care delivered. 

Because primary care visits are the most often-billed Part B services, these measures 
should at least be statistically stable. However, several panel members suggested that 
these measures might be poor access indicators because different beneficiaries might 
receive visits for different reasons (eg., preventive care versus acute care). Until the 
quality of the diagnosis coding on the new Part B records is known, however, it probably 
will not be possible to sort out the various reasons for visits. 

Number Of Physicians Serving Medicare Beneficiaries 

One possible adverse impact of changes in Medicare payment rates is that many physicians 
may seek to limit the number of Medicare patients that they treat. Hence, a reasonable 
indicator of good access to care would be the dispersion of Medicare services across 
physicians. A reduction in the number of physicians seeing Medicare patients may indicate 
a loss of mainstream care for beneficiaries. An additional provider-based indicator would 
be the number of beneficiaries changing physicians. Changes in this indicator might also 
show an increased unwillingness by some providers to serve Medicare beneficiaries. 7 

Technical problems with physician identifiers in the Medicare files may make this a 
difficult task. Prior to 1991, Medicare statistical files identified physicians only by carrier- 
assigned numbers. Numerous physicians could use the same number (eg., a single billing 
number for a group practice), while one physician might bill under several numbers. 

To quantify the magnitude of this problem, Commission staff took a sample amounting to 
1 percent of 1989 physician billing numbers. On a charge-weighted basis, only 30 percent 
of physicians used a unique identifier, with 70 percent reporting that multiple identifiers 
might be used by the same provider entity. This is clearly the result of variation across the 
carriers: eight carriers require unique numbers, while nearly all the remaining carriers 
allow multiple numbers per physician. About 60 percent of the billing numbers were for 
solo practitioners, while the remaining 40 percent were from group practices, clinics, and 
other practitioners. Thus it is appears unlikely that any accurate estimate of the extent of 


7 Measures of the number of beneficiaries switching physicians and the reason for loss of usual source of care 
will also be obtainable from the Current Beneficiary Survey. 


27 



concentration of Medicare services among physicians can be obtained from historical 
Medicare claims files. 

HCFA is moving toward a Unique Provider Identification Number (UPIN) system, under 
which each MD or DO would have one and only one billing number. Currently, however, 
only about 40 percent of CWF records have the UPIN on them, with the rest still being 
reported by the old carrier-assigned numbers. The HCFA Bureau of Program Operations 
does not plan to enforce use of the UPIN (ie., denial of claims) until January 1, 1992. 
Thus, there will be no good national pre/post 1992 time series based on the UPIN. 

It is possible that HCFA could map the old carrier identifiers to the new UPINs in an 
attempt to get some national trend data. Medicare’s directory of UPINs retains up to six 
carrier-assigned billing numbers for each UPIN. A project to crosswalk the UPINs and 
the old numbers is being discussed at HCFA, and Commission staff plan to make further 
inquiries in this area. 8 

There may be, in addition, strong restrictions on the use of the UPIN once it is fully 
implemented. Whereas employees of HHS may access the UPIN files for their official 
duties, no provision is made for government agencies outside of HHS other than the 
Department of Justice in case of legal action. Thus, it is unlikely that the PPRC would be 
able to perform a mapping of historical data to the new UPINs on its own, and would have 
to rely on a HCFA-provided mapping. 

Finally, HCFA has historical data on the number of physicians signing participation 
agreements. It is not clear, however, whether this data would be useful in tracking the 
concentration of Medicare services across physicians. 

Profiling Physicians Serving The Underserved 

.An additional physician-based analysis suggested by the Panel was to profile and track 
those physicians serving the underserved. Ideally, Commission staff would like to use the 
Medicare claims files to track these physicians. If UPIN-based information is provided, 
staff should be able at least to analyze counts in the number of physicians after 1992. 
However, due to restrictions on the use of the UPEN, staff may not be able to profile the 
characteristics of physicians. While HCFA’s UPEN directory will indicate such items as 
board certification, it seems unlikely at this point that such information will be made 
available to those outside of HCFA. 

Use Of Public Institutions 

The Panel suggested that increased use of public facilities might be one indicator of 
reduced access to private physicians. Staff have examined the potential for tracing the 
amount of care provided in public hospitals and other governmental funded facilities. 


8 However, it may be impossible to count the number of physicians within groups serving Medicare 
beneficiaries, since in some instances ail physicians within a group used the same billing ID in the historical data. 


28 



On the inpatient side, this is a relatively straightforward task. The HCFA Provider of 
Service file will allow the HCFA hospital identifiers to be selected for urban public 
hospitals. These hospital identifiers are keyed onto the Medicare Part A files, allowing 
the inpatient care in these facilities to be tracked easily. 

On the outpatient side, however, this may be much more difficult. Each visit to a hospital 
outpatient department generates a facility charge. The bill for this facility charge uses the 
same hospital identifier as the inpatient bill, so bills from public hospital OPDs should be 
recognizable. However, the hospital outpatient files have historically been among the least 
usable of HCFA datasets, and have never been publicly released. In addition, diagnoses 
have been coded using ICD-9-CM codes, and CPT codes have only recently been required. 
So far, compliance with the CPT coding requirement seems spotty, so it may not be 
possible to count individual services very accurately in this file. It probably is not possible 
to track public hospital use through physicians' bills. The provider number on these bills 
is the physician’s number, not the hospital’s. 

However, for other sorts of public outpatient providers it may be possible to track 
beneficiary usage. Federally-funded Comprehensive Health Centers and rural health 
clinics have their own provider identifiers in the HCFA provider of service file. However, 
it is not clear whether the Part B carriers use these numbers or assign their own provider 
numbers to these clinics in the same way that they do to other physician practices. 
Commission staff will investigate this further. 

Others 

The Panel suggested two other approaches to measuring access to care that will require 
considerable additional developmental work prior to implementation. First, episodes of 
care might be used to track adequacy of access. For example, individuals hospitalized with 
a heart attack should be seen by a cardiologist after discharge from the hospital. Lack of 
such followup care could be an indicator that beneficiaries do not have adequate access 
to care. Second, excess mortality is one poor outcome that may be linked to inadequate 
access. HCFA routinely releases case-mix-adjusted mortality data for hospitals. Similar 
indices may be constructed for populations using the date of death available on the Health 
Insurance Master File. 


SUMMARY OF VULNERABLE POPULATIONS, GEOGRAPHIC AREAS, AND 
MEASURES OF ACCESS 

Table 1 summarizes some of the above discussion on vulnerable populations, geographic 
areas, and measures of access using HCFA administrative datasets. 


29 


Table 1. Sum m a r y of Geographic Areas, Vulnerable Populations, and Measures of Access 



Proportion of 

Beneficiary Population I 

Directly Identifiable from 

1CFA Admtot*tratht» Data? 



AREAS 

Frontier Rural 

1 2 percent 

Yes 

Inner City 

Data not yet available 

Yes, by ZIP code 

HPSA 

Data not yet available 

Probably yes* 

Areas w/ Large Fee Reduction 

Data not yet available 

Yes 

Areas where Medicare Fees are 

Data not yet available 

Yes 

Lowest Relative to Other Payers 

Old old 

Approximately 10 percent 

Yes 

Disabled 

Approximately 10 percent 

Yes 

Mental 

Data not yet available 

Perhaps w/SSA Data* 3 

Other 

Data not yet available 

Perhaps w/SSA Data 

ESRD 

Less than half percent 

Yes 

Institutionalized 

Data not yet available 

No 

Dual Eligibles/QMBs 

Approximately 9 percent 

Yes 

Non-whites 

Data not yet available 

Yes 

Poor 

Data not yet available 

No 

No Medigap 

20 percent 

No 


MEASURES 



Sentinel Events 

Small percentage 

Yes 

Stage of Disease 

Small percentage 

Yes, using ICD-9-CM codes 

Excess mortality 

Small percentage 

Yes 

Number of Physicians 

100% 

Only after 1/1/92** 

Use of Public Providers 

Data not yet available 

Possibly 

Episodes of Care 

Data not yet available 

Yes 

Primary Care Utilization 

Large percentage 

Yes 


Notes: * An approximate ZIP code crosswalk can be obtained by overlaying physical maps of HPSAs with ZIP 

code maps. 

b The mentally disabled may be identifiable through patterns of service use (e.g. psychiatric services). 

c The institutionalized may be identifiable through patterns of service use (e.g. nursing home care). 

d It may be possible to crosswalk the new unique physician IDs to the carrier-assigned IDs to produce 
trend data. 


30 





































































































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TECHNICAL NOTES ON 
SOURCES AND USES OF DATA 
FOR MONITORING ACCESS 


This section of the Appendix describes several sources of data and their potential uses in 
monitoring access to care. The core of HCFA’s data collection efforts is the Common 
Working File (CWF), which is described in detail in the first section. Following that, data 
sources that are immediately available for monitoring access are detailed. Finally, data 
sources available only in the longer term are described. 


THE COMMON WORKING FILE 

The Common Working File (CWF) is the core of HCFA’s information systems. All Part 
A and Part B claims processed on behalf of beneficiaries end up in the CWF. In addition 
to identifying the services and payments, each claim also identifies the beneficiary and 
provider. Other files allow detailed information on beneficiary and provider characteristics 
to be merged with the claims information in the CWF. 1 

The CWF is a relatively new system for aggregating claims information. A small portion 
of 1989 claims were processed through the CWF, as were a significant portion of 1990 
claims. As of January 1, 1991, all Part A and Part B records were maintained through the 
CWF. 

The CWF represents a substantial improvement over prior HCFA information processing 
systems. For the first time, all Part A and Part B claims lines are maintained in a single 
centralized location at HCFA in Baltimore. Claims processing has also been streamlined, 
and the HCFA Office of the Actuary indicates that claims run-out times have been cut in 
half. That is, the percentage of claims processed within six months of incurred date under 
the CWF is equal to the percentage of claims that had been processed within a year of the 
incurred date under the old payment record system. 

The CWF is also set up for much more rapid data retrieval. First, records for the 
standard HCFA five percent beneficiary sample are kept on-line (or "near-line") and are 
readily accessible to HCFA staff. Second, HCFA has established a "prospective tap" 
process, where every accepted CWF transaction (ie., every clean claim, paid or denied) is 


1 Beneficiary information comes from the Health Insurance Master (HIM) file. Information on institutional 
providers comes from the Provider of Services (POS) file. Information on physicians comes from the Medicare 
Provider Identification and Eligibility System (MPEES), also known as the Unique Provider Identification Number 
(UPIN) file. 


31 




screened and copied to on-line databases based on beneficiary ID, physician ID, ZIP code, 
or other factors. Thus, claims for specific subsets of the population can be monitored on 
a flow basis. * 2 

The CWF will also retain more information than previous HCFA data processing systems. 
For the first time, line-item detail for all Part B claims is retained. Of particular interest, 
diagnosis codes (ICD-9-CM) are recorded on the claim, up to 3 (possibly 4) on each bill 
describing the patient’s general condition, and one additional diagnosis for each procedure 
billed. However, the accuracy or completeness of the diagnosis coding is not clear at this 
point, and Commission staff will inquire further into this. 

The downside of the CWF is that it is huge. A current estimate is that all Part B bills for 
10 percent of beneficiaries for one year would require at least 175 standard reels of 
computer tape, and possible many more. Further, HCFA may not have much spare 
capacity within their data processing center to generate substantial new files. 3 


SOURCES AND USES OF DATA FOR IMMEDIATE MONITORING OF ACCESS 

This section of the appendix briefly outlines some strategies for monitoring access to care 
that might be put into place in time for the January 1, 1992 implementation of physician 
payment reform. 

Write-Off Files From The Common Working File 

First, it should be relatively straightforward to obtain access to records for the standard 
HCFA five percent beneficiary sample 4 , either directly or by requesting summary statistics 
from HCFA. This may not be adequate, however, for some of the smaller vulnerable 
populations identified by the Panel (eg., individuals in HPSAs), for analyzing subsets of 
the vulnerable populations, or for applying some of the measures of access that depend 
on fairly rare events, such as the sentinel events. 


For example, claims for the 25,000 beneficiaries in the Current Beneficiary Survey sampling frame are 

cumulated on a weekly (Part B) or monthly (Part A) basis. At the present time, this is the largest such 
"prospective tap" that HCFA has installed within the CWF system. 

3 HCFA is doing a considerable amount of CWF data processing on behalf of the Agency for Health Care 
Policy and Research, which in turn transfers several million dollars per year to support HCFA <fara processing 
efforts. It is not clear what priority non-paying requests would have. 

Five percent of all non-ESRD beneficiaries, and 100 percent of ESRD beneficiaries. This amounts to 
roughly 1.7 million beneficiaries. 


32 



Second, the Commission might request that population-specific files be created on batch 
basis from the existing 1991 CWF records and on a "prospective tap" basis for the 1992 
records. This would require some negotiation with HCFA data processing staff and 
others, and the size of the population so sampled would be constrained by some notion of 
feasibility and reasonableness. 

One approach to monitoring access immediately after January 1, 1992 would be to request 
a sample of records from the Common Working File on a flow basis. That is, all Part A 
and Part B records for selected areas or populations could be written to tape cartridges 
on a weekly or monthly basis for analysis. 

While this is technically feasible, it would involve a substantial amount of work, both at 
HCFA and at the Commission. The largest "prospective tap" currently in place in the 
CWF system collects records for approximately 25,000 beneficiaries, or less than 0.1 
percent of the beneficiary population. It might be possible to acquire information on 
substantially larger samples of beneficiaries, particularly if we restrict the sampling to sub¬ 
samples of the standard HCFA 5 percent beneficiary sample. However, the cost of 
collecting and processing the data would grow accordingly. 

Use Of HCFA Summary Data 

An alternative to the detail of the CWF would be to analyze summary data provided by 
HCFA. Utilization information for some of the geographic areas (eg., payment areas) and 
population types (eg., disabled, ESRD) may be tabulated on a routine basis by HCFA. 
However, this information is likely to be in terms of gross outlays or outlays by type of 
service, and we are not likely to be able to track the more refined measures of access. 

Currently, most HCFA summary data are of two types. First, there are a number of 
annual summary files produced. These typically track outlays by geographic area and 
broad beneficiary population groups (eg,, age categories). Typically, these files have been 
available only with a considerable lag, often several years. 

A second set of summary statistics consists of carrier workload reports and Treasury 
outlays. These are often produced monthly, but are on paid basis, that is, they reflect the 
number of claims processed, not the amount of care delivered at any one time. Typically, 
these reports would reflect only gross aggregates such as total expenditure by type of 
service. 

The Commission may wish to explore developing an arrangement with HCFA to generate 
some more detailed and timely summary statistics. For example, there are only about 10 
million Part A final bills submitted each year. Measures of access based on Part A 
utilization (eg., some of the sentinel events) might be tracked fairly easily and quickly and 
on a reasonably detailed basis. 


33 


Surveys Of Beneficiaries And Physicians 


An alternative to claims data for monitoring of access in 1992 would be surveys of 
beneficiaries or physicians. 

Surveys of beneficiaries may be an important source of information on the immediate 
effects of payment reform. Staff contacted the American Association of Retired Persons 
(AARP). Although AARP used to do annual surveys on a wide range of issues concerning 
older Americans, it is now moving to custom surveys on special topics. AARP staff have 
expressed willingness to explore cooperation with the Commission in this area. 

Rather than rely on existing surveys of beneficiaries, the Commission may wish to 
undertake its own surveys to obtain immediate feedback on physician payment reform. 
To obtain reliable estimates for the geographic areas and vulnerable populations discussed 
above, this would require a fairly substantial sample of beneficiaries. The Commission 
may wish to contract with national survey organizations for a large-scale survey of 
beneficiaries. 

Physician organizations are another potential sources of information on the immediate 
impact of payment reform. Staff identified four organizations who have recently surveyed 
physicians: the North Carolina chapter of the American Society of Internal Medicine 
(NCSIM), the American Academy of Family Physicians, the Minnesota Medical 
Association, and the American Medical Association. The American Medical Association 
is currently doing research on the access issue, and may introduce access measures in it 
the physician surveys that it routinely fields. The American Urological Association is also 
conducting a large survey of its membership on access and other issues. This is not an 
exhaustive list, and there are probably other significant physicians survey projects of which 
Commission staff are unaware. 

Beneficiary Focus Groups 

A final option for immediate feedback on the impact of payment reform would be to 
organize beneficiary focus groups. The Commission has had some success (using 
Mathematica Policy Research as a contractor) in conducting some focus-group type work 
in developing a Commission survey of beneficiary understanding of assignment and 
participation in the Medicare program. However, this option probably would not lead to 
easily quantifiable data. 


34 



SOURCES AND USES OF DATA FOR LONGER-TERM MONITORING OF ACCESS 


The principal difference between the short-run strategies mentioned above the strategies 
available in the longer run is that several detailed datasets will become available in late 
1993 or early 1994. These would include the following: 

Part B Medicare Annual Data (BMAD) Files 

The Part B Medicare Annual Data (BMAD) file system consists of annual summaries and 
samples of Part B non-institutional claims. Currently, each carrier submit its BMAD files 
to HCFA, which then edits and combines the carrier submissions to generate national files. 
The BMAD files typically are released one year after the close of the calendar year. 
HCFA staff plan to continue to generate BMAD-like files from the Common Working File 
data. It is not clear at this point whether any of the new information available in the CWF 
record (eg., diagnosis code) will be added to the BMAD records. 

There are four separate BMAD files. The first (BMAD-I) summarizes all Part B claims 
(other than facility charges) by carrier, physician specialty, and CPT code. Thus, with 
some modification, this file could be used to calculate area-specific utilization rates for 
carrier charge localities. It could not, however, be used to examine utilization for smaller 
areas (eg., HPSAs, ZIP codes). The second (BMAD-II) is the list of prevailing charges 
across the various carrier charge localities. It will become obsolete after the Medicare Fee 
Schedule is introduced. The third (BMAD-HI) contains all claims lines for a five percent 
sample of all providers, while the fourth (BMAD-IV) contains all claims lines for a five 
percent sample of beneficiaries. 5 

Medicare Provider Analysis And Review (MEDPAR) File 

The MEDPAR file contains all Part A inpatient discharge abstracts for a fiscal year. 
These records retain multiple ICD-9-CM procedure and diagnosis codes, as well as other 
information such as length of stay and discharge status. In addition to the standard 
MEDPAR file, a relatively new file called the QC-MEDPAR exists. This file contains 
additional information concerning readmission and death after discharge from the hospital. 
These records are available for the universe of Medicare beneficiaries. 

Survey Data 

Data from two national surveys should be available in the years after 1992. These are the 
Current Beneficiary Survey (CBS) and the Health Interview Survey (HIS). 


5 Plus 100 percent of all ESRD beneficiaries. 


35 



Some aspects of the data are common to both surveys. First, the sample sizes are small 
enough to preclude some levels of analysis. For example, the CBS will sample about 
12,000 Medicare beneficiaries, while the HIS sample contains roughly the same number 
of individuals over age 65. This would make estimates of some sentinel conditions, smaller 
vulnerable populations, and smaller areas relatively volatile across years. 

Second, both surveys contain health status and health care utilization information. For the 
HIS, that information is based on the recall of the respondents. For the CBS, claims 
information from the Medicare statistical system will be appended to the responses. In 
addition, the CBS will contain a series of questions aimed directly at changes in access. 

Other Non-Medicare Trend Data 

A further option in the long run would be to track expenditures and utilization for 
populations other than Medicare. Several sources of non-Medicare data may be available. 

State Hospital Discharge Abstract Data. Currently 29 states have some mandate to 
generate hospital utilization information. However, only about 14 states generate usable 
hospital discharge abstract files. 6 In addition, this information is generally available only 
with a considerable lag. For instance, no state has a 1990 file yet available, several states 
have 1989 files, but the majority of states have only a 1988 or earlier file available. 

One possible alternative to the use of state hospital discharge abstracting systems is the 
Commission on Professional and Hospital Activities (CPHA) data. CPHA collects hospital 
discharge abstract information on a very timely basis from some of its member hospitals. 
However, the sample of CPHA reporting hospitals is not uniformly distributed across 
areas, and it may be difficult to generate population-based use rates from these data. 

The MEDSTAT Data. MEDSTAT gathers claims for the employees of approximately 100 
large organizations and analyzes those claims for their client organizations. MEDSTAT 
currently produces about 30 million outpatient claims annually, with a reasonably even 
geographic distribution across urbanized areas of the U.S. They claim to be able to 
generate good national use rates, but cannot generate reliable state-level utilization rates 
for much of their data. However, for about half of their data, they can generate 
population-based utilization rates for sub-national areas. 

The HIAA Data. The Health Insurance Association of America (HIAA) produces data 
showing submitted and covered charges for a number of procedures. However, those data 


6 This information comes from a recent telephone survey conducted by Greg Dodds of Consolidated 
Consulting Group. Many of the largest states have discharge abstract datasets, including New York, California, 
and Florida. 


36 



have generally been used for pricing purposes, and it is not clear that good utilization rates 
can be calculated from them. 

National Center for Health Statistics. The NCHS gathers information on a number of 
important medical services for a sample of the U.S. population using the HIS and other 
sources. These data may be sufficient for national comparison with Medicare trends. 

Other. Other payers may be willing to provide data for their populations. The Civilian 
Health and Medical Program for the Uniformed Services (CHAMPUS) is national in 
scope and maintains detailed utilization files on its enrollees. Similarly, the Federal 
Employees’ Program (FEP) is the national Blue Cross and Blue Shield insurer for Federal 
employees. It too collects detailed claims information across the United States. 
Commission staff have not contacted either of these institutions yet to inquire about data 
availability. 


37 


















































SUMMARY AND TENTATIVE WORKPLAN 


This appendix has described in detail many feasible approaches to monitoring access both 
immediately and in the longer run. The Commission is now considering its options for 
monitoring access. 

Clearly, the first focus of work must be on access measures to be put into place prior to 
the implementation of physician payment reform. The phase-in of the Medicare Fee 
Schedule is now less than a year away, and any action that will be taken to monitor access 
in the short run must be planned and implemented now. 

In terms of data sources, at this juncture probably the most reasonable approach is to 
concentrate on readily available HCFA claims datasets. Part B claims for the standard 5 
percent beneficiary sample, and Part A claims for all beneficiaries are both large but 
manageable files. Thus, analysis for the first year may focus on these two files. 

Much work needs to be done to validate the numerous proposed measures of access using 
existing data. Existing historical files (the BMAD and MEDPAR files) provide claims 
information for 5 percent of Part B and 100 percent of Part A claims. Thus, these 
historical files can be used to examine the validity and reliability of the various measures 
of access discussed here. Once having settled on a reliable set of measures, the 
Commission may pursue obtaining more recent data from HCFA and tracking trends in 
these measures of access. 

The Commission will also examine the availability of beneficiary and physician survey data. 
While probably less precise than claims files, such data could provide a meaningful and 
timely supplement to claims-based analysis. 

Finally, the Commission reiterates its belief that HCFA should routinely report detailed 
Part A and Part B utilization statistics in a manner that will allow other interested parties 
to assess changes in beneficiaries’ access to care. A common set of data available to all 
would enhance dialogue on beneficiaries’ access to care and preserve confidence in the 
Medicare program. 


REFERENCES 

Department of Health and Human Services, Report to Congress: Monitoring Changes in Use 
of, Access to, and Appropriateness of Part B Medicare Services, U.S. Department of 
Health and Human Services, Washington, DC, 1991. 


38 



Health Resources and Services Administration, Incorporating Health Status Indicators into 
the Measurement of Medical Underservice, Contract Number 240-86-0056, Health 
Resources and Services Administration, Public Health Service, U.S. Department 
of Health and Human Services, Washington, DC, 1987. 

Physician Payment Review Commission, Medicare Volume Performance Standard Rate of 
Increase for Fiscal Year 1991 , Washington, DC, 1990. 

United Hospital Fund of New York, Measuring Avoidable Deaths and Diseases in New York 
State , United Hospital Fund of New York Paper Series 8, January 1988. 




































































































































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